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Before You Submit a Complaint

All complaints submitted regarding claims must have a date of medical services rendered no more than four years prior to the date of the complaint submission.

To be eligible for a case review, your Complaint must have been reviewed by the Payor's Dispute Resolution process, or it must have been pending within that process for more than 45 working days. If you submit a complaint to the Department prior to participating in the Payor’s Dispute Resolution process, your complaint will be closed without review.

Prior to filing your complaint with the Department of Managed Health Care, please determine if your complaint is against a health plan (or a Medical Group or IPA that is contracted with a health plan) licensed under the Knox-Keene Health Care Service Plan Act of 1975. A list of all licensees is available. We are only able to review complaints against Knox-Keene licensees. Please verify your complaint concerns one of these health plans. Please be aware that with the exception of Blue Cross of California and Blue Shield of California, the Department does not have jurisdiction over most PPO plans. We do not have jurisdiction over self-funded plans although a self-funded plan may be administered by a Knox-Keene licensee.

We do not have jurisdiction over Blue Cross Life and Health products. Blue Cross Life and Health products are regulated by the California Department of Insurance. Please see the Department of Insurance regarding complaints about Blue Cross Life and Health.

The Department is unable to review complaints against Medicare Managed Health Plans. Complaints against Medicare Managed Health Plans should be submitted to the Centers for Medicare and Medicaid Services (CMS).